Prescriptions of NSAIDs to patients undergoing third molar surgery : an observational, prospective, multicentre survey

Comparative Effect of Celecoxib, Diclofenac, and Ibuprofen in Controlling Postoperative Pain, Edema, and Trismus After Third Molar Extraction: A Double-Blinded Randomized Controlled Trial

The objective of this study was to compare celecoxib, diclofenac, and ibuprofen for managing postoperative pain, swelling, and trismus after a third molar extraction. There were 90 patients included and randomly allocated, 30 in each of the three study groups. The primary outcome of this trial was postoperative pain, and the secondary outcomes were postoperative swelling and trismus. The celecoxib and diclofenac groups showed better postoperative pain control compared to ibuprofen. Moreover, diclofenac showed better pain control compared to both celecoxib and ibuprofen within the first 72 hours postoperatively: one hour (p=0.005), six hours (p=0.001), 12 hours (p=0.044 ), 24 hours (p=0.017), 48 hours (p=0.006), and 72 hours (p=0.012 ). Regarding the secondary outcomes, there was no statistical difference in the swelling and trismus measurements during the postoperative period between the three study groups. The results of this study showed that celecoxib pain management post-third molar extraction is comparable to that of diclofenac and superior to that of ibuprofen.

Comparison of Pain Levels With Postoperative Intramuscular Administration of Single-Dose Ketoprofen Versus Diclofenac Sodium in Patients Undergoing Lower Third Molar Surgery

Background Third molar surgeries are commonly performed in oral and maxillofacial surgery practice. Pain associated with this procedure is usually a frequent reason for patient apprehension and discomfort. Oral analgesics, though effective, do not provide sufficient pain relief in the immediate postoperative period.  Aim To assess the postoperative effect on pain levels of single-dose administration of ketoprofen and diclofenac sodium as an injection in patients undergoing third molar removal surgeries.  Methods This study was conducted among 30 patients divided into two groups (n=15). Patients in Group K received injection ketoprofen 100 mg and Group D included patients receiving injection diclofenac sodium 75 mg, both intramuscularly postoperatively. The intensity of pain was assessed at 30 minutes, two, six, and eight hours post-surgical removal of the impacted tooth using the visual analogue scale (VAS). The statistical data was analyzed using SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). The comparative statistical test adopted to compare pain scores between the two groups was the Independent samples t-test. A p-value of <0.05 was considered to be statistically significant. Results Our study results revealed that Group K patient's VAS scores after two hours, six hours, and eight hours were 3.9 ± 2.7, 4.5 ± 3.23, 2.93 ± 2.27 respectively. In Group D patient's VAS scores after two hours, six hours, and eight hours were 4.83 ± 2.82, 5.03 ± 2.9, 3.73 ± 2.91 respectively. Patients who were administered ketoprofen had lower pain levels when compared to patients who were given diclofenac but the difference was not statistically significant at any time point (p=0.172 after eight hours). Our results depicted that the pain levels uniformly reached their maximal levels six hours after the procedure and thereafter steadily declined in both groups.  Conclusion It can be concluded from the study that both the drugs ketoprofen and diclofenac sodium analyzed in this study can be used interchangeably for the reduction of pain following lower third molar surgery.

Is it time US dentistry ended its opioid dependence?

BACKGROUND

In 2017, 11.4 million US citizens misused prescription opioids, resulting in 46 overdose deaths daily and a $78.5 billion burden on the economy. Dentists are one of the most frequent prescribers of opioids, and there is concern that dental prescribing is contributing to the opioid crisis.

METHODS

A 2019 study showed 22.3% of US dental prescriptions were for opioids compared with 0.6% of dental prescriptions in England where nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen accounted for most analgesic prescriptions. This observation prompted a review of international analgesic prescribing habits and of the advantages and disadvantages of opioids and NSAIDs for treating dental pain.

RESULTS

US opioid prescribing far exceeded that in other countries where NSAIDs accounted for most dental analgesic prescribing. Furthermore, results from reviews published respectively in 2018 and 2016 help confirm that NSAIDs and NSAID-acetaminophen combinations are as effective as or more effective than opioids for controlling dental pain and cause significantly fewer adverse effects.

CONCLUSIONS

In light of the potential for misuse and evidence that NSAIDs are as effective as opioids and have fewer adverse effects, there is clear patient benefit in avoiding opioids for the prevention or management of dental pain.

PRACTICAL IMPLICATIONS

A growing preponderance of evidence shows that opioids are not needed for routine oral health care. This article provides an overview of the evidence and outlines possible pain management models to minimize opioid use in dentistry. The purpose is to stimulate debate about this important topic and encourage the development of definitive guidance by professional bodies, health care providers, and state and federal agencies.

Efficacy of Ketoprofen With or Without Omeprazole for Pain And Inflammation Control After Third Molar Removal

In view of the gastrointestinal problems generated by the ketoprofen use, the ketoprofen association with omeprazole is available on the market. However, this association efficacy in acute pain control has not been established. Bilateral extraction of lower third molars in similar positions is currently the most used model for the evaluation and investigation of the efficacy and pharmacological effects of new compounds for the treatment of acute postoperative pain. The randomized and crossover study consisted in evaluating the clinical efficacy of therapy performed by ketoprofen 100 mg (twice daily-b.i.d.) versus ketoprofen 200 mg + omeprazole 20 mg (once daily-q.d.) to pain, swelling and trismus control in the bilateral extraction model of lower third molars in similar positions in two different appointments, in 50 volunteers. Volunteers reported significantly less postoperative pain at various post-operative periods and consumed less rescue analgesic medication (acetaminophen 750 mg) throughout the study when they took the combination of ketoprofen 200 mg + omeprazole 20 mg (q.d.). Following administration of both study drugs, no gastrointestinal adverse reactions were reported by volunteers. Furthermore, the evaluations of the drugs in pain control by the volunteers were significantly favorable to ketoprofen 200 mg + omeprazole 20 mg (q.d.). For swelling and trismus control, the treatments presented similar results. In conclusion, when volunteers took ketoprofen 200 mg + omeprazole 20 mg (q.d.), they reported significantly less postoperative pain at various post-surgical periods and consumed less rescue analgesic medication throughout the study compared with ketoprofen 100 mg (b.i.d).

A Comparative Study of Oral Analgesics for Postoperative Pain After Minor Oral Surgery

We compared the effects of preoperative administration of diclofenac sodium, celecoxib, and acetaminophen on postoperative pain in patients undergoing minor oral surgery under general anesthesia. One hundred twenty-eight patients were randomly divided into 4 groups preoperatively treated with diclofenac sodium 50 mg, celecoxib 400 mg, acetaminophen 1000 mg, or placebo. Postoperative pain was managed using intravenous patient-controlled infusion of fentanyl. Assessments included levels of postoperative pain by using visual analog scale (VAS) scores at 4, 5, and 6 hours after administration of the test drug; consumption of fentanyl up to each time point; and time to first requirement for fentanyl. Our study demonstrated that, for diclofenac sodium and celecoxib in comparison with placebo, there were significantly lower VAS scores at 4, 5, and 6 hours after oral administration of the study drug; a longer period of time to first requirement for fentanyl after surgery; and less consumption of postoperative fentanyl. A similar analgesic effect versus placebo was noted for acetaminophen but only at the 5- and 6-hour time points. In contrast, no significant differences in VAS scores at 4 hours after administration or time to first requirement for fentanyl were observed between acetaminophen and placebo. Furthermore, no significant differences in measurements were observed between the study drugs at any time point. These findings suggest that oral administration of celecoxib 400 mg is suitable for controlling postoperative pain, and as effective as diclofenac sodium 50 mg. Acetaminophen 1000 mg also exerts analgesic effect with slower onset for postoperative pain.

Acute pain: a multifaceted challenge - the role of nimesulide

BACKGROUND

This article summarizes the outcome from an international consensus meeting, which took place in Vienna on 4 November 2014.

SCOPE

The aim of the meeting was to provide the state of the art on the pathophysiology and treatment of acute pain with special emphasis on nimesulide, a non-steroidal anti-inflammatory drug (NSAID) indicated for the treatment of acute pain and primary dysmenorrhea. Besides the data on the mechanisms of acute inflammatory pain and on the efficacy and safety of nimesulide in patients affected by different forms of acute pain, the clinical experience of attending experts was discussed based on selected case reports.

RESULTS

The members of this consensus group recognized that nimesulide is a NSAID highly effective in the treatment of several painful situations with an acute inflammatory component including primary dysmenorrhea. Although safety concerns regarding nimesulide have emerged in recent years, both robust new epidemiological data and clinical experience confirm a positive benefit/risk profile of nimesulide in the treatment of several forms of acute pain.

CONCLUSIONS

The members of this international consensus group concluded that nimesulide, when used appropriately, remains a particularly valuable and safe option for the treatment of several conditions characterized by the presence of acute inflammatory pain because of the rapid onset of the analgesic action, and the positive evidence-based benefit/risk profile.

Single dose of diclofenac or meloxicam for control of pain, facial swelling, and trismus in oral surgery

Background

Postoperative pain associated with removal of mandibular third molars has been documented from moderate to severe during the first 24 hours after surgery, with pain peaking between 6 and 8 hours when a conventional local anesthetic is used. Dental pain is largely inflammatory, and evidence-based medicine has shown that nonsteroidal anti-inflammatory drugs are the best analgesics for dental pain. The aim of this study was to compare the analgesic, anti-inflammatory and anti-trismus effect of a single dose of diclofenac and meloxicam after mandibular third molar extraction.

Material and Methods

A total of 36 patients were randomized into two treatment groups, each with 18 patients, using a series of random numbers: Group A, was administered 100 mg of diclofenac; and Group B, 15 mg of meloxicam. Drugs were administered orally 1 hour prior to surgery. We evaluated pain intensity, analgesic consumption, swelling, as well as trismus.

Results

The results of this study showed that patients receiving 15 mg of meloxicam had less postoperative pain (P=0.04) and better aperture than those receiving 100 mg of diclofenac (P=0.03). The meloxicam group presented less swelling than diclofenac group; however, significant statistical differences were not observed.

Conclusions

Data of this double-blind, randomized, parallel-group clinical trial demonstrated that patients receiving 15 mg of preoperative meloxicam had a better postoperative analgesia and anti-trismus effect compared with who were given 100 mg of diclofenac after third molar extractions.

Key words:Diclofenac, meloxicam, dental pain, trismus, third molar surgery.

Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons

This study was designed to evaluate the variations in decision making among Brazilian oral and maxillofacial surgeons (OMFS) and trainees in relation to third molar surgery. A survey on 18 diverse clinical situations related to the assessment and treatment of the third molar surgeries was conducted during the 20th Brazilian National OMFS meeting. Participants were divided into three groups according to their level of training. Another variable studied was length of experience. Correlation between the question answers and the variables was analysed using the chi-square test and the f test. The mean age of participants was 32.68 years, and their mean length of experience was 5.24 years. There were no statistical differences between the level of training and number of years of experience and the responses to 15 of the 18 questions on clinical situations. However, differences were found in responses to prophylactic extraction of asymptomatic third molars, use of non-steriodal anti-inflammatory drugs (NSAIDs) during the preoperative surgical period and the use of additional imaging to plan extractions. The group with shorter time of experience (3.8 ± 3.94 years) tended to recommend extractions of asymptomatic third molars more frequently compared with the more experienced surgeons (P = 0.041). More experienced surgeons used NSAIDs in the preoperative surgical period, whereas the majority of the youngest surgeons (4.1 ± 5.96 years of experience) did not (P = 0.0042). The certificated trained and in practice group tended to treat deep lower third molar impactions based on the findings of a panoramic radiograph, without obtaining additional imaging [cone beam computed tomography (CBCT)] before treatment (P = 0.0132). Decision making regarding third molar treatment differs according to the level of training and is influenced by the number of years of experience. Therefore, further continuous education programmes in this area are warranted to make recommendations regarding third molars consistent with the current literature.

Comparison of the effect of naproxen, etodolac and diclofenac on postoperative sequels following third molar surgery: a randomised, double-blind, crossover study

Objectives: To compare the three non-steroidal anti-inflammatory agents (NSAIDs) diclofenac potassium, etodolac and naproxen sodium in relation to pain, swelling and trismus following impacted third molar surgery. Study Design: The study was a randomized and a double-blinded study which included 42 healthy young individuals with impacted third molars and bone retention. Patients were randomly assigned to 3 groups (n: 14) to which diclofenac potassium, naproxen sodium and etodolac were administered orally an hour before the operation. Impacted third molars were surgically extracted with local anaesthesia. Visual analog scales (VAS) were used to assess the pain in the 6th, 12th hours and on the 1st, 2nd, 3rd, 5th, and 7th days postoperatively. Swelling was evaluated using ultrasound (US) and mouth opening (trismus) was measured with a composing stick pre and post operatively on the 2nd and 7th days respectively. Results: Regarding pain alleviation, diclofenac potassium was better than naproxen sodium and naproxen sodium was better than etodolac but these differences were not statistically significant. US measurements showed that the swelling on postoperative 2nd day was significantly lowest with diclofenac potassium as compared to others (p= 0.027) while naproxen sodium and etodolac acted similarly (p=0.747). No difference was noted regarding trismus in any of the groups. Conclusions: NSAIDs (diclofenac, naproxen and etodolac) are somehow similarly effective for controlling pain and trismus following extraction of mandibular third molars but diclofenac potassium surpasses others in reduction of swelling.

Key words:Diclofenac potassium, naproxen sodium, etodolac, impacted third molar surgery, pain, swelling, trismus.

Therapeutic efficacy and tolerability of the topical treatment of inflammatory conditions of the oral cavity with a mouthwash containing diclofenac epolamine: a randomized, investigator-blind, parallel-group, controlled, phase III study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs), including diclofenac, are the mainstay of analgesic and anti-inflammatory treatment in dentistry. Diclofenac epolamine [diclofenac N-(2-hydroxyethyl)pyrrolidine; DHEP] is a diclofenac salt with greater water solubility and better cutaneous absorption properties than other commonly used forms of the drug. IBSA has recently developed a mouthwash formulation of DHEP for the topical treatment of inflammatory conditions of the oral cavity.

OBJECTIVE

The aim of this study was to compare the efficacy and tolerability of DHEP mouthwash (Osmal®) with that of a reference product (commercially available diclofenac mouthwash).

METHODS

This was a randomized, investigator-blind, parallel-group, controlled, phase III study that enrolled 80 patients with conditions affecting the oral cavity, characterized by an inflammatory component, and eligible for analgesic and anti-inflammatory treatment. Patients were randomized 1:1 to DHEP mouthwash (0.103% DHEP in aqueous solution) or to diclofenac mouthwash (0.074% free diclofenac in aqueous solution). The treatment regimen was the same in both groups: 1-minute rinse with 15 mL of mouthwash, twice daily for 7 days. Visits were scheduled at study inclusion (D0), and 3 days (D3) and 7 days (D7) after treatment initiation. During each visit assessments were made of pain severity (using a 5-point semi-quantitative scale and a 100-mm visual analogue scale [VAS]) and inflammatory signs (using a 5-point scale). The primary study endpoint was the change in pain severity scores from D0 to D3 and D7. Secondary endpoints included effects of treatment on inflammation score, quality of sleep, compliance with treatment and the safety and tolerability of treatment.

RESULTS

The two treatment arms were homogeneous in terms of patient characteristics. The most prevalent oral condition was gingivitis. Overall both topical treatments were effective in alleviating pain and inflammation, as evidenced by decreases in pain and inflammation scores within 3 days after treatment initiation. Notably, a significantly greater proportion of patients treated with DHEP were free of pain and inflammatory symptoms at D3 compared with those treated with the diclofenac mouthwash (40% vs 20% of patients; p < 0.05). Also, DHEP was associated with more marked, but not statistically significant, decreases in VAS pain scores versus baseline after 3 days' treatment. Compliance with both treatments was good and both mouthwashes were well tolerated.

CONCLUSION

DHEP mouthwash was at least as effective as diclofenac mouthwash at alleviating pain and inflammation symptoms and is well tolerated in patients with painful inflammatory conditions of the oral cavity. The potential of DHEP mouthwash deserves to be investigated in a larger patient population.